Evaluation of telehealth delivery of interdisciplinary treatment for persisting post-concussion symptoms after mild traumatic brain injury (i-RECOveR-TH): a randomised control trial

All participants will receive intervention from a neuropsychologist, physiotherapist, and sports medicine physician via telehealth. Participants will be posted equipment packs to facilitate physiotherapy treatment via telehealth, including heart rate monitor, paddle pop sticks, laminated pages with numbers and checkers, and a ruler. All participants will receive 3 initial 60–90-minute consultations independently with a neuropsychologist, physiotherapist, and medicine physician. Telehealth will be facilitated using online video conferencing. Following initial consultations, clinicians will meet via video conference to discuss individualised treatment plans. Participants will then be offered up to an additional 7 sessions each of neuropsychology, physiotherapy, and medical treatment as required (i.e., including initial consultations, up to 24 sessions in total across the disciplines will be available based on clinical need). Telehealth treatment sessions will be delivered online via videoconference. Psychological treatment sessions will last between 60-90 minutes at a maximum of once a week. Physiotherapy treatment sessions will last for 45-60 minutes and will be at a maximum of once a week. Participants will also be offered ongoing medical management/review/consultations as required over the 8-week program. The psychological intervention will be oriented toward a cognitive-behavioural framework as described by Beck (1979) and will be adapted from previous manuals developed by Ferguson and Mittenberg (1996) and Silverberg et al. (2013) and will comprise of goal setting and review, psychoeducation, activity scheduling, cognitive restructuring, anxiety management training, cognitive compensation intervention and sleep intervention. As part of this therapy, participants will be provided with educational materials adapted from readily available resources (published materials such as the Mild Head Injury Bookelet; https://www.monash.edu/medicine/psych/merrc/resources) as well as provided with material specially designed for this study. Participants will also be assessed by a physiotherapist and will be provided treatment in the following domains as required: ocular, vestibular, cervical, and autonomic system functioning. Physical therapy intervention will be specific to their assessment and may comprise of vestibular rehabilitation, manual therapy, cervical strengthening, proprioceptive training, and a graded exercise program. Examples of ocular retraining include convergence exercises where participants will watch a target as it moves towards them, saccadic retraining where participants quickly move their gaze between targets, and smooth pursuit training where the participant watches a moving target. Examples of vestibular rehabilitation are gaze stabilisation where participants turn their head and focus on a target (this is done to a particular speed predetermined by the physiotherapy assessing the participant), VOR cancellation exercises where participants watch a target move through space by turning their whole body, and motion sensitivity exercises such as, walking, and gaze stabilisation or VOR cancellation. Examples of cervical rehabilitation include cervical strengthening such as deep neck flexor strengthening, and proprioception training with a target and a laser to rehabilitate sensory awareness of the neck. Graded exercise is defined as exercise of the participant's choice that can be safely done for 20 minutes. Exercise will be targeted at a particular heart rate. The starting heart rate will be defined as 85% of the point of failure of the subject on Montreal Virtual Exertion test. Heart rates will increase in line with a decrease in participant's symptoms. This will be assessed and closely monitored by the physiotherapist. Graded exercise will generally be walking, running or stationary bike, however, other modes such as swimming could be introduced if tolerated and preferred by the participant. The physiotherapist will outline an individualised treatment and home program based on the assessment. Equipment used throughout the assessment and rehabilitation include various targets (a paddle pop, sticky labels), balls for motion sensitivity and a heart rate monitor for tracking heart rate. Medical management of persistent post-concussion symptoms will comprise of one consultation (same as initial consultation) with the physician which may include pharmacological management of symptoms as well as advice regarding return to activities (e.g. work, sport, school). Treatment fidelity: Adherence to the manualised CBT intervention will be rated by an independent psychologist who will listen to audio/video recordings of 10% of the sessions. To assess physiotherapy treatment fidelity, 10% of the sessions will be rated by an independent physiotherapist.